Dysthymia F34.1 - ICD10 Description, World Health Organization
A chronic depression of mood, lasting at least several years, which is not sufficiently severe, or in which individual episodes are not sufficiently prolonged, to justify a diagnosis of severe, moderate, or mild recurrent depressive disorder (F33.-).
This disorder represents a consolidation of DSM-IV-defined chronic major depressive disorder and dysthymic disorder. An individual diagnosed with persistent depressive disorder (dysthmia) needs to meet all of the following criteria:
Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
Presence, while depressed, of two (or more) of the following:
Poor appetite or overeating.
Insomnia or Hypersomnia.
Low energy or fatigue.
Low self-esteem.
Poor concentration or difficulty making decisions.
Feelings of hopelessness.
During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the above symptoms for more than 2 months at a time.
Criteria for a major depressive disorder may be continuously present for 2 years.
There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder.
The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism).
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Note: Because the criteria for a major depressive episode include four symptoms that are absent from the symptom list for persistent depressive disorder (dysthymia), a very limited number of individuals will have depressive symptoms that have persisted longer than 2 years but will not meet criteria for persistent depressive disorder. If full criteria for major depressive episode have been met at some point during the current episode of illness, they should be given a diagnosis of major depressive disorder. Otherwise, diagnosis of other specified depressive disorder or unspecified depressive disorder is warranted.
This common disorder is a chronic depression whose symptoms are less severe than those in major depressive disorder. Its depressive symptoms must be present most days over at least a 2-year period (1 year in children and adolescents). Major depressive disorder may precede this disorder, and major depressive episodes may occur during persistent depressive disorder. Individuals whose symptoms meet major depressive disorder criteria for 2 years should be given a diagnosis of persistent depressive disorder as well as major depressive disorder.
Effective Therapies
Individuals with persistent depressive disorder (dysthmia) may respond to psychotherapy, pharmacotherapy, or a combination of both. The medications that are effective in treating major depressive disorder are also effective in persistent depressive disorder (dysthmia). These individuals require a longer treatment period, more psychotherapy sessions, and/or higher doses of antidepressant medication than do patients with acute forms of depression. Treatments effective for young adult dysthymic patients may not be as useful in elderly persistent depressive disorder (dysthmia) patients. Cognitive behavioral therapy (CBT), interpersonal therapy (IPT), and cognitive behavioral analysis system of psychotherapy (CBASP) are effective for the treatment of patients with this disorder. The rate of relapse/recurrence of symptoms has been shown to be reduced by long-term treatment with antidepressant medication and with long-term use of specific psychotherapies.
Ineffective Therapies
Vitamins, dietary supplements, and acupuncture are all ineffective for mood disorders.
Lack Of Social Skills During Persistent Depressive Disorder
There are social skills that are essential for healthy social functioning. During persistent depressive disorder, individuals lack the essential social skills of self-confidence, optimism, belonging, and sociability. These are the same social skills that are lacking in individuals with major depressive disorder, avoidant personality disorder and social anxiety disorder.
Social Skills That Are Lacking During Persistent Depressive Disorder
SOCIAL SKILL
LOW LEVEL
HIGH LEVEL
Self-Confidence
Feeling inferior or shy
Having a good opinion of one’s self and abilities; socially confident and out-going
Optimism
Pessimism or expecting the worst
Having a positive outlook on life; expecting a good outcome; hopeful
Belonging
Fearing rejection by others
Feeling liked and accepted by friends, and included in their group; not fearing rejection
Sociability
Social withdrawal
Friendly; interested in social contacts and activities
Which Behavioral Dimensions Are Involved?
The ancient Greek civilization lasted for 1,300 years (8th century BC to 6th century AD). The ancient Greek philosophers taught that the 5 pillars of their civilization were: wisdom, courage, community, moderation, and justice. Psychiatry named the opposite of each of these 5 ancient themes as being a major dimension of psychopathology (i.e., irrationality, negative emotion, detachment, disinhibition, and antagonism). (Psychology named these same factors the "Big 5 dimensions of personality": "intellect", "neuroticism", "extraversion", "conscientiousness", and "agreeableness")
Wisdom vs Irrationality:N/A Courage vs Negative Emotion:
Depressed mood
Low self-confidence, pessimism, loneliness and hypersensitivity to rejection
Community vs Detachment:N/A Moderation vs Disinhibition:N/A Justice vs Antagonism:N/A
Prevalence
The U.S. 12-month prevalence is 0.5%. In adulthood, women are 2-3 times more likely to develop this disorder than men.
Course
This chronic disorder usually has an early and insidious onset in childhood or adolescence. In adults, up to 75% of individuals with this disorder will develop major depressive disorder within 5 years. The spontaneous recovery rate for this disorder is approximately 10% per year. This recovery rate is significantly better with active treatment. Personality disorders and substance use disorders are more likely to be associated with this disorder if persistent depressive disorder starts before age 21.
Familial Pattern
Persistent depressive disorder is more common in the first-degree biological relatives of individuals with this disorder, and those with major depressive disorder.
Complications
By definition, there must clinically significant distress or impairment in social, occupational, or other important functioning as result of this depression. In childhood, this disorder is often associated with impaired school performance and poor social interaction. Children and adolescents with this disorder are usually irritable and cranky as well as depressed. They have low self-esteem, poor social skills, and are pessimistic.
Comorbidity
In adults, this disorder is associated with an increased risk of having major depressive disorder, anxiety disorders, substance use disorders, and personality disorders (i.e., avoidant, dependent, obsessive-compulsive, borderline, histrionic, narcissistic and antisocial).
Associated Laboratory Findings
No laboratory test has been found to be diagnostic of this disorder. Sleep EEG abnormalities are evident in 25%-50% of adults with this disorder. These are the same EEG sleep abnormalities that are found in major depressive disorder (e.g., reduced rapid eye movement [REM] latency, increased REM density, reduced slow-wave sleep, impaired sleep continuity). Dexamethasone nonsuppression (which often occurs in major depressive disorder) is not common in persistent depressive disorder (unless it co-exists with major depressive disorder).
A randomized clinical trial of a brief, problem-focused couple therapy for depression. (2010) "Results showed a significant effect of treatment in reducing women's depressive symptoms, with 67% of women improved and 40% to 47% recovered at follow-up, compared to only 17% improved and 8% recovered among women in the control group. Treatment was also effective in secondarily improving women's marital satisfaction, reducing husbands' levels of psychological distress and depression-specific burden, and improving both partners' understanding and acceptance of depression."
A comparative trial of psychotherapy and pharmacotherapy for "pure" dysthymic patients. (2005) "This article reports outcomes of an acute randomized trial of 94 subjects treated for 16 weeks with either interpersonal psychotherapy (IPT), brief supportive psychotherapy (BSP), sertraline, or sertraline plus IPT... Response rates were 58% for sertraline alone, 57% for combined treatment, 35% for IPT, and 31% for BSP."
Randomized, double-blind, placebo-controlled trial of fluoxetine treatment for elderly patients with dysthymic disorder. (2005) "Fluoxetine had limited efficacy in elderly dysthymic patients. In the intent-to-treat sample, response rates were 27.3% for fluoxetine and 19.6% for placebo. The clinical features of elderly dysthymic patients are typically distinct from those of dysthymic disorder in young adults, and the findings suggest that treatments effective for young adult dysthymic patients may not be as useful in elderly dysthymic patients."
Randomized, double-blind, placebo-controlled trial of fluoxetine treatment for elderly patients with dysthymic disorder. (2005) "Response rates were 27.3% for fluoxetine and 19.6% for placebo. Fluoxetine had limited efficacy in elderly dysthymic patients. The clinical features of elderly dysthymic patients are typically distinct from those of dysthymic disorder in young adults, and the findings suggest that treatments effective for young adult dysthymic patients may not be as useful in elderly dysthymic patients."
Cognitive behavioral therapy for depressed older outpatients--a controlled, randomized trial. (2004) "After cognitive behavior therapy 36 of 65 patients were in complete remission but only 4 of 35 patients on the waiting list. Only 1 patient under cognitive behavior therapy has to be considered as treatment failure." [Editor: I find this claim that only 1 CBT patient was a treatment failure extremely hard to believe.]
Community-integrated home-based depression treatment in older adults: a randomized controlled trial. (2004) "Patients were randomly assigned to the Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) intervention (n = 72) or usual care (n = 66). The PEARLS intervention consisted of problem-solving treatment, social and physical activation, and potential recommendations to patients' physicians regarding antidepressant medications. At 12 months, compared with the usual care group, patients receiving the PEARLS intervention were more likely to achieve complete remission from depression (36% vs 12%)."
A comparison of active drugs for the treatment of dysthymia. (2003) "All studied drugs promoted similar clinical responses, although with different side effect profiles. The evidence for TCAs and SSRIs was the most robust, considering the number of trials and participants."
Benefits and risks of pharmacotherapy for dysthymia: a systematic appraisal of the evidence. (2003) "Regarding placebo-controlled trials (n = 16), similar results were obtained in terms of efficacy for different groups of drugs, such as tricyclic antidepressants (TCAs) [NNT= 4.3], selective serotonin reuptake inhibitors (SSRIs) [NNT= 5.1], monoamine oxidase inhibitors (MAOIs) [NNT= 2.9]. In general, patients treated with a TCA were more likely to report adverse events, compared with placebo and SSRIs."
Treatment of dysthymia and minor depression in primary care: a randomized trial in patients aged 18 to 59 years. (2001) "This was an 11-week randomized placebo-controlled trial conducted in primary care practices. Paroxetine (n=80) or placebo (n=81) therapy was started at 10 mg per day and increased to a maximum 40 mg per day, or Problem-Solving Treatment for Primary Care (PST-PC) was provided (n=80). There were 6 scheduled visits for all treatment conditions. For dysthymia the remission rate for paroxetine (80%) and PST-PC (57%) was significantly higher than for placebo (44%).
A comparison of drugs versus placebo for the treatment of dysthymia. (2000) Regarding placebo-controlled trials (n = 15), "similar results were obtained in terms of efficacy for different groups of drugs, such as tricyclic antidepressants (TCAs) [NNT= 4.3], selective serotonin reuptake inhibitors (SSRIs) [NNT= 4.7], monoamine oxidase inhibitors (MAOIs) [NNT= 2.9]. Drugs are effective in the treatment of dysthymia with no differences between and within class of drugs. Tricyclic antidepressants are more likely to cause adverse events and dropouts."
Treatment of dysthymia and minor depression in primary care: A randomized controlled trial in older adults. (2000) "Patients were randomly assigned to receive paroxetine (n = 137) or placebo (n = 140), starting at 10 mg/d and titrated to a maximum of 40 mg/d, or problem-solving treatment-primary care (PST-PC; n = 138). For the paroxetine and placebo groups, the 6 visits over 11 weeks included general support and symptom and adverse effects monitoring; for the PST-PC group, visits were for psychotherapy. For dysthymia, paroxetine improved mental health functioning vs placebo among patients whose baseline functioning was high or intermediate. Mental health functioning in dysthymia patients was not significantly improved by PST-PC compared with placebo."
Treatment of primary dysthymia with group cognitive therapy and pharmacotherapy: clinical symptoms and functional impairments. (1999) "Treatment with sertraline, with or without group cognitive behavior therapy, reduced the functional impairment of depression. The reductions were similar in the drug-cognitive therapy group and in subjects who received the drug alone. Furthermore, while group cognitive behavior therapy alone reduced the depression scores, this effect was not significantly greater than the effect of the placebo."
The long-term outcome of dysthymia in private practice: clinical features, temperament, and the art of management. (1999) "The highest level of adaptive functioning was observed among fluoxetine-treated dysthymics (50% of responders [N = 12] achieved DSM-III-R GAF score of 81-90). Of TCA-treated patients, 39% had intolerable side effects, necessitating switch-over to fluoxetine. Agitation occurred in 11% of fluoxetine-treated patients (N = 4) and was associated with nonresponse and/or dropout; otherwise, this selective serotonin reuptake inhibitor was well tolerated, thereby contributing to long-term compliance. More provocatively, patients with dysthymia who had required extensive psychotherapeutic attention prior to state-of-the-art pharmacotherapy no longer required such therapy."
Controlled efficacy study of fluoxetine in dysthymia. (1997) "After three months of treatment, response was seen more frequently in the fluoxetine group (42/72) than in the placebo group (14/39, P < 0.0001). Improved patients at 3 months were still improved at 6 months. Furthermore, 50% of the nonresponders at 3 months improved and rated as responders at 6 months, after fluoxetine was increased to 40 mg daily."
